Possibilities of endoscopic diagnosis of opportunistic infections in patients with HIV/tuberculosis co-infection

Radiation pneumonitis complicated by Pneumocystis carinii in patients with thoracic neoplasia: a clinical analysis of 7 cases

The pattern of the development of opportunistic infections (OIs) in HIV-infected patients was evaluated, based on a cohort of 1,530 patients enrolled in two AIDS Clinical Trials Group anti-retroviral studies. We quantified the increase in risk of OIs associated with the occurrence of a previous OI. This assessment was based on the observed event rates of the more common AIDS-defining OIs: Pneumocystis carinii pneumonia (PCP), Mycobacterium avium complex (MAC), cytomegalovirus (CMV), and a systemic mycosis. Additionally, for each OI, we assessed the relative risks associated with a history of prior OIs, changes in CD4 levels, and baseline prognostic factors. We found that the occurrence of each of these OIs increased the risk of subsequent OIs, even after adjusting for the CD4 count. Specifically, the occurrence of PCP significantly increased the risk of MAC and CMV, and somewhat increased the risk of systemic mycoses. Diagnosis with MAC was associated with an increased risk of subsequent CMV, whereas the occurrence of CMV increased the risk of MAC. Finally, once patients were diagnosed with a systemic mycosis, they were at a somewhat increased risk of subsequently developing MAC or CMV. Although current practice for determining the timing and initiation of prophylactic therapies relies chiefly on CD4 count, the occurrence of specific AIDS-defining OIs in patients with HIV infection should also be taken into account in making decisions regarding prophylaxis strategies.

The CARI guidelines. CMV disease and kidney transplant: treatment of cytomegalovirus disease in renal transplant recipients.

An outbreak of 29 cases of Pneumocystis jirovecii pneumonia (PCP) occurred among renal and liver transplant recipients (RTR and LTR) in the largest Danish transplantation centre between 2007 and 2010, when routine PCP prophylaxis was not used. P. jirovecii isolates from 22 transplant cases, 2 colonized RTRs, and 19 Pneumocystis control samples were genotyped by restriction fragment length polymorphism and multilocus sequence typing analysis. Contact tracing was used to investigate transmission. Potential risk factors were compared between PCP cases and matched non-PCP transplant patients. Three unique Pneumocystis genotypes were shared among 19 of the RTRs, LTRs, and a colonized RTR in three distinct clusters, two of which overlapped temporally. In contrast, Pneumocystis control samples harbored a wide range of genotypes. Evidence of possible nosocomial transmission was observed. Among several potential risk factors, only cytomegalovirus viremia was consistently associated with PCP (P=0.03; P=0.009). Mycophenolate mofetil was associated with PCP risk only in the RTR population (P=0.04). We identified three large groups infected with unique strains of Pneumocystis and provide evidence of an outbreak profile and nosocomial transmission. LTRs may be infected in PCP outbreaks simultaneously with RTRs and by the same strains, most likely by interhuman transmission. Patients are at risk several years after transplantation, but the risk is highest during the first 6 months after transplantation. Because patients at risk cannot be identified clinically and outbreaks cannot be predicted, 6 months of PCP chemoprophylaxis should be considered for all RTRs and LTRs.

The tragic history of AIDS in the hemophilia population, 1982-1984.

Incidence trends for the 13 most frequent AIDS-defining opportunistic infections (OIs) among men who have sex with men (MSM, n = 15,588) and injecting drug users (IDUs, n = 4475) were examined using data abstracted from medical records in >90 hospitals and clinics in nine US cities during 1991-1996. Among MSM, the most frequent OIs were Mycobacterium avium complex (MAC) disease, Pneumocystis carinii pneumonia (PCP), and cytomegalovirus (CMV) retinitis; decreasing (P < or = .05) trends occurred for 11 OIs (MAC disease, PCP, CMV retinitis, Kaposi's sarcoma, esophageal candidiasis, CMV disease, extrapulmonary cryptococcosis, toxoplasmic encephalitis, tuberculosis, chronic herpes simplex, and disseminated histoplasmosis). Among IDUs, the most frequent OIs were PCP, MAC disease, and esophageal candidiasis; decreasing trends occurred for 5 OIs (PCP, esophageal candidiasis, tuberculosis, chronic herpes simplex, and chronic cryptosporidiosis) and an increase occurred in recurrent pneumonia. The differences in trends for MSM and IDUs may be due to differences in medical care and adherence to preventive medications.

Background: Pneumocystis jiroveci pneumonia (PJP) is an opportunistic fungal infection primarily affecting immunocompromised individuals. It carries a high mortality rate of 33-69% [1,2]. Recent studies have shown that COVID-19 can have prolonged effects on pulmonary function and immune system regulation [3,4]. Additionally, COVID-19 has been associated with temporary immunosuppression, potentially increasing susceptibility to opportunistic infections [5]. This case series investigates the occurrence of PJP in patients with a history of COVID-19 infection, contributing to the amplifying amount of evidence on post-COVID complications. Methods: This case series examines six patients diagnosed with PJP following COVID-19 infection. The study group comprised of predominantly males (83.3%), with ages ranging 37 to 69 years (mean 54). Comorbidities were prevalent, notably diabetes mellitus type 2 and hyperlipidemia (66.7% each), hypertension (50%), and a history of tobacco use (66.7%). All patients tested positive for fungitell and two (33.3%) tested positive for PJP. The interval between COVID-19 infection and PJP diagnosis varied from one week to 22 months. Treatment strategies differed, ranging from trimethoprim-sulfamethoxazole alone to combinations with corticosteroids. The mortality rate was 33.3%, with two patients succumbing during hospitalization. Survivors were discharged on prophylactic trimethoprim-sulfamethoxazole, underscoring the potential long-term implications of this opportunistic infection in post-COVID patients. Discussion: The affected patients had diverse demographics, ranging from 37 to 69 years old, with various comorbidities. The timing between COVID-19 infection and PJP diagnosis varied, spanning from 1 week to 22 months. Patients underwent different treatments, including the use of trimethoprim-sulfamethoxazole and corticosteroids. The mortality rate of 33.3% emphasizes the severity of PJP in post-COVID patients. Previous case series enforced our observation that high-risk patients should be monitored for PJP and other opportunistic infections after a COVID-19 infection [6]. This case series emphasizes the need for continued research of long-term effects of COVID-19 on the immune system and potential increased vulnerability to opportunistic infections. Conclusion: This case series suggests a link between prior COVID-19 infection and opportunistic infections like PJP, even in patients without traditional risk factors such as HIV. It emphasizes the importance of monitoring post-COVID patients for unusual infections and further investigating the long-term immune system effects of COVID-19. Healthcare providers should maintain a high index of suspicion for PJP and other opportunistic infections in patients with a history of COVID-19, even months after recovery. Further large-scale studies are warranted to better understand this relationship and inform future prevention strategies and treatment protocols.

Cytomegaloviruses (CMVs) are ubiquitous but highly species specific agents and are a common cause of infections in many animal species including humans (Weller, 1971). The characteristic cellular changes caused by CMV including cell enlargement with intranuclear inclusions were first reported in 1881 by Ribbert in the kidneys of a stillborn infant with congenital syphilis (Ribbert, 1904). Subsequent reports have described similar findings in the parotid glands of children and in the salivary glands from guinea pigs. It was initially thought that cytomegalic inclusion disease (CID) of the newborn was the sole manifestation of human CMV (HCMV) infection (Goodpasture and Talbot, ; Lipschutz, ; Cole and Kuttner, ; Lowenstein, 1907). Several groups of investigators have simultaneously isolated and propagated HCMV from infants and children with CID and from adenoidal tissue of children undergoing adenoidectomy (Rowe et al., ; Smith, ; Weller et al., 1957). As tissue culture isolation and serological assays became more widely available, HCMV was linked to a variety of illnesses, many of which have subsequently been shown to be unrelated to HCMV. A common characteristic of patients at risk for invasive HCMV infections is the suppression of host immune responsiveness. The onset of AIDS epidemic in the early 1980s has led to a dramatic expansion of the spectrum of HCMV disease. HCMV was the most common opportunistic infection in patients with AIDS and a major cause of morbidity and mortality in these patients until the introduction of highly active antiretroviral therapy (Jacobson et al., ; Gallant et al., ; Munoz et al., ; Spector et al., 1999). Currently, HCMV continues to cause disease in patients with AIDS, but similar to other opportunistic infections in AIDS patients responding to antiretroviral therapy, the incidence of invasive HCMV disease is extremely low even in those with minimally reconstituted immune systems (Jacobson et al., 2001). Currently, HCMV is a cause of significant morbidity and mortality in newborn infants who acquire HCMV prenatally and in allograft recipients.

Thoracic manifestations of the acquired immune deficiency syndrome

Are European-specific guidelines needed for prevention of opportunistic infections in HIV-1?

Pneumocystis jirovecii pneumonia (PCP) is an important cause of morbidity and mortality in kidney transplant recipients (KTRs), and prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMX) is recommended. The aim of this study was to investigate incidence and risk factors for PCP in KTRs after 6-month TMP-SMX prophylaxis. We conducted a case-control study of patients with PCP who received 6-month PCP prophylaxis with TMP-SMX after kidney transplantation (KT). In cases of rejection, PCP prophylaxis was provided for six additional months after anti-rejection therapy. Cytomegalovirus (CMV) infection was not considered an indication for PCP prophylaxis due to concerns of nephrotoxicity associated with TMP-SMX. Among 3941 kidney or pancreas-kidney transplant recipients, 67 (1.7%) developed PCP after discontinuing TMP-SMX. A total of 47 patients with KT PCP and 94 controls were included. Duration of PCP prophylaxis was similar between cases and controls (median 6months, P=.53). In multivariate analysis, rejection (OR 3.9; 95% CI 1.4-11.1) and CMV infection (OR 2.4; 95% CI 1.0-5.8) were independently associated with PCP development after TMP-SMX. Rejection or CMV infection was observed in 70% of patients with PCP. Time to PCP development after rejection (median [IQR] 6 [5-19] months) was slightly shorter than after CMV infection (median [IQR] 9 [5-12] months; P=.18). Post-prophylaxis PCP occurred in <2% of KTRs, and about two-thirds of these experienced rejection or CMV infection. These data suggest that at least 6 to 9-month additional chemoprophylaxis may be needed to prevent PCP in KTRs with transplant rejection or CMV infection.

The frequency of nine reactivating or opportunistic infections and Kaposi's sarcoma among patients with the acquired immunodeficiency syndrome (AIDS) was reviewed. The diagnoses of 87 patients reported from the Colorado AIDS registry and 359 others from literature reports were abstracted, and data were placed in one of 11 categories on the basis of the risk group of the patient. Pneumocystis carinii infection was significantly commoner among blood or blood-product recipients than among natives of the tropics (P less than .001). Tuberculosis and toxoplasmosis each were significantly commoner among natives of the tropics than natives of developed countries (P less than .001), whereas disseminated Mycobacterium avium-Mycobacterium intracellulare infections were present more often in the latter group. Among natives of the tropics treated in developed countries, cytomegaloviral infection was diagnosed significantly less often (22%) than among persons from developed countries in whom sexual transmission was presumed (47%; P = .0005). These data suggest that the pattern of infections manifested in AIDS could provide clues about transmission and that there may be a hierarchy of reactivation of latent infections in which populations with exposure to multiple agents manifest these preferentially to Pneumocystis carinii.

Objective:To assess the impact of opportunistic diseases on survival in patients with HIV disease.Methods:A cohort of 2081 patients followed for a mean of 30 months was studied. Time-dependent Cox proportional hazards analyses were performed using incident opportunistic diseases and CD4 cell counts as independent variables.Results:During follow-up, 730 (35%) patients died. The occurrence of Pneumocystis carinii pneumonia (PCP), cytomegalovirus (CMV) disease, Mycobacterium avium complex (MAC) disease, Candida esophagitis, Kaposi's sarcoma, lymphoma, progressive multifocal leukoencephalopathy (PML), dementia, wasting, toxoplasmosis, and cryptosporidiosis were all significantly associated with death, independently of CD4 cell count (all P&lt;0.001 for opportunistic diseases controlling for CD4 cell count). The magnitude of increased risk was greatest for lymphoma (relative hazard [RH], 7.2), PML (RH, 3.9), MAC (RH, 3.0) and CMV (RH, 2.2). Cryptococcosis (RH, 0.94) and herpes zoster (RH, 0.85) were not associated with death. In a multivariate Cox proportional hazards analysis, MAC (RH, 2.56; 95% confidence interval [CI], 2.1-3.1), CMV (RH, 1.63; 95% CI, 1.1-2.1), toxoplasmosis (RH, 1.85; 95% CI, 1.1-2.6), PCP (RH, 1.19; 95% CI, 1.1-1.1), and CD4 cell count were significantly associated with death. Patients who had opportunistic diseases had significantly greater monthly declines in CD4 counts (−11 × 106/L per month) than those who did not (−6 × 106/L per month; P&lt;0.001).Conclusion:Most opportunistic diseases increase the risk of death independently of CD4 cell count. These data support the hypothesis that opportunistic diseases enhance HIV pathogenesis and further underscore the importance of prophylaxis.

To assess the impact of opportunistic diseases on survival in patients with HIV disease. A cohort of 2081 patients followed for a mean of 30 months was studied. Time-dependent Cox proportional hazards analyses were performed using incident opportunistic diseases and CD4 cell counts as independent variables. During follow-up, 730 (35%) patients died. The occurrence of Pneumocystis carinii pneumonia (PCP), cytomegalovirus (CMV) disease, Mycobacterium avium complex (MAC) disease, Candida esophagitis, Kaposi's sarcoma, lymphoma, progressive multifocal leukoencephalopathy (PML), dementia, wasting, toxoplasmosis, and cryptosporidiosis were all significantly associated with death, independently of CD4 cell count (all P<0.001 for opportunistic diseases controlling for CD4 cell count). The magnitude of increased risk was greatest for lymphoma [relative hazard (RH), 7.2], PML (RH, 3.9), MAC (RH, 3.0) and CMV (RH, 2.2). Cryptococcosis (RH, 0.94) and herpes zoster (RH, 0.85) were not associated with death. In a multivariate Cox proportional hazards analysis, MAC [RH, 2.56; 95% confidence interval (CI), 2.1-3.1], CMV (RH, 1.63; 95% CI, 1.3-2.1), toxoplasmosis (RH, 1.85; 95% CI, 1.3-2.6), PCP (RH, 1.29; 95% CI, 1.1-1.5), and CD4 cell count were significantly associated with death. Patients who had opportunistic diseases had significantly greatly monthly declines in CD4 counts (-11 x 10(6)/l per month) than those who did not (-6 x 10(6)/l per month; P <0.001). Most opportunistic diseases increase the risk of death independently of CD4 cell count. These data support the hypothesis that opportunistic diseases enhance HIV pathogenesis and further underscore the importance of prophylaxis.

Life-threatening Pneumocystis jiroveci Pneumonia with Cytomegalovirus Coinfection in a Follicular Lymphoma Patient During Rituximab-based Chemotherapy